1. UMMS CRIT Module III: Discharge Planning and Transitions of Care Catherine DuBeau, MD Chief of Geriatrics University of Massachusetts

2. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Discharge Planning and Transitions of Care: Where are they going and why? Opening the Black Box

3. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable. She is delirious, hypertensive, and severely impacted The last labs sent with her are from 3 days old; Hgb was 7.8 and creat 2.2. You call the hospital and the floor RN says the pt was discharged on the previous shift and she knows nothing about the patient. Exercise

4. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable. She is delirious, hypertensive, and severely impacted The last labs sent with her are from 3 days old; Hgb was 7.8 and creat 2.2. You call the hospital and the floor RN says the pt was discharged on the previous shift and she knows nothing about the patient. Exercise This is a routine skilled nursing facility admission

5. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation BirthMarriage Age 50 Retirement Death Episodes of Serious Illness A Life Courtesy Peter Boling, MD

6. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Hospital: A-fib, Stroke Hospital: MI, CHF Hospital: CHF 6 days 4 days8 days 18 days in hospital, 35 days in NH, 135 days of homecare, 312 days at home Scope of the Problem: Hospital Admission = First of Multiple care transitions Nursing Home Stay 35 Home Health Episodes 45 2862 Courtesy Peter Boling, MD

7. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation AHRQ HCUPnet http://www.ahrq.gov/data/hcup/factbk1/10shel.htm Discharge from Hospital to Other Institutions increases with Age

8. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation All team members should participate − begin early in hospital course Site of care after D/C should be warranted by patient’s needs MD: Assess medical care needs, provide D/C summary and orders, do med reconciliation Discharge Planning

9. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation All team members should participate − begin early in hospital course Site of care after D/C should be warranted by patient’s needs MD: Assess medical care needs, provide D/C summary and orders, do med reconciliation Transition Planning

10. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Home Home with services Inpatient Rehab Chronic Care Hospital Skilled Nursing Facility (SNF) Hospice Where can patients go after hospitalization?

11. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Who Pays For What? Medicaid to qualify, income and assets must be below state eligibility levels $880/$2,000 indiv, $1090/$3,000 couple $8,000 set aside in burial contract Medicare Age > 65 Part A – hospital, SNF, hospice; no premium Part B – MD visits, outpatient expenses, home health care; pay premium Part D – medications

12. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation House, apartment; alone, with spouse and/or other family Senior Housing Continuing Care Retirement Community (CCRCs) Assisted Living Facilities, Residential Care Facilities, Board and Care Nursing Home Many possible options for “Home”

13. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

14. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

15. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

16. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation The provision of diagnostic, therapeutic or support services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function, and health. Home Care AMA Council on Scientific Affairs, JAMA 1990; 263 1241-1244 Levine SA et al. JAMA 2003; 290:1203-1207.

17. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Medicare Services in Home Care Part A (hospital) –Visiting nurse –HHA –SW –Mental Heath –Dietician –OT/PT/ST Part B (20% co-pay) –MD Home Visit –Durable medical equipment –Diagnostics

18. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation A physician can refer any patient with an acute skilled need to a home care agency Nursing care –Monitoring of vital signs, cor/pulm status –Wound care –DM monitoring and education –Medication management PT and OT Speech therapy Medicare: “Skilled” Home Care via Certified Home Health Agency

19. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Durable Medical Equipment Covered by Medicare (mostly) Specific Requirements Courtesy of Jeremy Boal, MD

20. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Non Durable Equipment Adult Incontinence Pads Chux Booties Gloves Wound care supplies Not covered by Medicare May be covered by Medicaid

21. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Homemaker All bathroom equipment Transportation Personal or supportive long-term care What Medicare Doesn’t Pay For

22. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Medicare pays if 3 day/night in hospital and 24 hr skilled nursing care needed –Duration of coverage depends on types and number of skilled needs Integrates features of acute care/rehab Interdisciplinary staffing –Nursing: RN, LPN, CNA, wound care –Therapies: PT/OT/ST, nutrition, SW, etc –Medical: MD, PAs, NPs –Other clinical: dental, podiatry, vision, psych, psychology, clinical pharmacist Skilled Nursing and Rehab in Nursing Homes

23. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Phlebotomy/Laboratory Radiology EKG Venous dopplers IVs: peripheral, PICC, etc No Dobhoffs or Central Lines Ancillary Services

24. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Needs and can tolerate intensive PT/OT (3 hrs/day) Medically unstable for SNF –Needs frequent MD evaluation (> q1-2 wk) –Rising Cr, dropping Hgb –Meds will need adjustment in < 24-48 hr (eg, BP meds, diuretics) –Needs telemetry, daily/STAT labs Acute Inpatient Rehab

25. UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Medical needs –Summary of admitting problems and course –Active Problem list –Recent and important pending labs –Reconciled Medication List (incl admit meds and all changes) and allergies –Advance directives: DPOA-HC, preferences, goals Functional support (ADL, IADL) –Disposition: where from and where next –Functional status: baseline and present –Social support and contact info Nursing needs: monitoring, wounds Rehabilitative needs: PT, OT 4 Core Elements of Transition Information and Communication